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FDAR Wound Care and Patient Assessment

The nurses note documents the care provided to a patient on October 20th. The patient was admitted at 8:00am via wheelchair with an IV saline infusion. At 3:30pm the patient reported feeling cold and had an elevated temperature of 37.7°C which the nurse addressed with a tepid sponge bath. Later at 5:40pm the patient's temperature had decreased to 37.0°C. At 5:45pm the nurse noted a gunshot wound on the patient's left forearm with pink discharge and provided wound dressing care, demonstrating proper techniques and advising on wound care. At 11:00pm the nurse checked the patient, noting a temperature of 37.1°C and intact wound

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Sherena Nicolas
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413 views1 page

FDAR Wound Care and Patient Assessment

The nurses note documents the care provided to a patient on October 20th. The patient was admitted at 8:00am via wheelchair with an IV saline infusion. At 3:30pm the patient reported feeling cold and had an elevated temperature of 37.7°C which the nurse addressed with a tepid sponge bath. Later at 5:40pm the patient's temperature had decreased to 37.0°C. At 5:45pm the nurse noted a gunshot wound on the patient's left forearm with pink discharge and provided wound dressing care, demonstrating proper techniques and advising on wound care. At 11:00pm the nurse checked the patient, noting a temperature of 37.1°C and intact wound

Uploaded by

Sherena Nicolas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
  • Nursing Notes and Observations

Date and

time Focus Nurses note/ DAR


20 Received patient on wheel chair awake, weak, responsive with
October,2021 an IVF of Normal Saline regulated at 100ml/hr infusing via right
8:00am metacarpal vein----------------------------------SQN

D.”Parang giniginaw man ako” as verbalized, patient covers


3:30pm Elevated Body self with blanket,Body temp of 37.7°c, skin warm to
Temperature touch.----------SQN
3:35pm A. Explained the need to do tepid sponge bath; provided tepid
sponge bath advised wife to continue; Checked any ordered
antipyretic medications and time last given; Encouraged to------
increase oral fluid intake---------------------------------------------------
4:00pm SQN
5:40pm Impaired Skin -Rechecked body temperature with result of
integrity 37.0°c-----------------SQN
5:45pm D-with gunshot wound on left forearm; noted few pinkish
discharges on wound dressing.-----------------------------------------
SQN
A. Assessed for moderate to severe wound pain, assessed for
5:55pm numbness on left digits; noted doctors order to do wound
dressing BID; explained to patient the importance of wound
dressing-----------------------------------------------------------------------
SQN
-Provided wound dressing aseptically; Demonstrated proper
hand hygiene and explained its importance; Advised not to
11:00pm touch or scratch the wound; Advised to do range of motion
exercises on left digits; Encouraged to include vitamin C and
protein rich foods on meals. Provided teaching about the
importance of ongoing antibiotics treatment compliance;
Elevated side rails for safety---SQN
R- body temperature of 37.1°c, wound dressing intact, no
other complaints noted, seen asleep with side rails
up-------------------SQN
( Signature)

Date and time Focus Nurses note/ DAR 20 October,2021 8:00am 3:30pm 3:35pm 4:00pm 5:40pm 5:45pm 5:55pm 11:00pm Elevated Body

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